Abstract

Introduction: In this study, a survey was prepared for urologists that asked about their primary choice of treatment for urolithiasis in daily practice and their answers were evaluated.Methods: The survey was prepared on the Google Docs website and it was sent to 1,016 urologists via email with 752 confirmed deliveries. In addition to the demographic questions about each participant's age, gender, and institution, the survey presented case scenarios focusing on their preferred treatment modalities for distal ureteric, proximal ureteric, and renal calculi. The participating urologists were divided into two groups according to the frequency that they treat urolithiasis patients.Results: Of the 752 surveys delivered, 211 urologists (28.05%) responded and 204 answered all questions. According to the results, there were no significant differences between the treatment approaches and the other localizations, but there was a statistically significant difference for treatment approaches to lower pole stones between two groups. In response to the question of which stone treatment method was used less frequently, 124 (60.7%) participants answered that they used shock wave lithotripsy less in the last 10 years.Conclusion: The present study has shown that while the management of renal and ureteric calculi by Turkish urologists is highly varied, the overall treatment patterns are in accordance with the European Association of Urology guidelines. However, similar to the global trend extracorporeal shock wave lithotripsy is less preferred by Turkish urologists.

Comments
1

This report is based on results from replies to a questionnaire delivered to more than 750 urologists in Turkey. Although the response rate was not higher than approximately 30 percent, the attitudes to different stone removing procedures seem to be representative for the global trends. But the most interesting part of the study can be found in the different explanations of why SWL was rated low.

More than 90% of the urologists replied that other treatment modalities had taken the place as the leading technology. This situation is indeed well recognized and it has for some time been obvious that the development of endoscopic instruments and improved methods for stone disintegration better have attracted the surgical minds of large groups of urologists.

The second reason for the changed methodology, emphasized by more than 70% of the urologists, is the low single session success rate. In this regard it is important to know that there is a considerable variation. Although repeated sessions often are the price that has to be paid for the non-invasive technique there is a wide range of re-treatments reflecting both how SWL treatment is carried out and the performance of the lithotripter. There is no doubt that with increased focus on how to carry out SWL, much better results should be expected than those sometimes reported in the literature.
That the patients’ preference was given as a reason in more than 25% of the responses needs to be further analyzed in detail. It is highly likely that in the majority of cases patients’ preference directly reflects the methodological choice favored by the treating urologists. How the patient decides is most certainly strongly dependent on how the method is presented to the patient.

Limited indications for SWL were considered as one reason for not choosing SWL, but in fact the range of indications is much more extensive than generally considered. One amazing observation was that so few urologists used SWL for treatment of stones in the distal ureter. In the reviewer’s experience this is an excellent indication for SWL with very high stone free rates despite low need of repeated treatment.

According to Figure 1 in the article, approximately 8% of the urologists had obvious concerns about the function of the lithotripter that they had been using. One problem is that shockwave lithotripters sometimes are considered together with piezoelectric lithotripters. This is not fair because disintegration with piezoelectric lithotripsy is usually inferior to that accomplished with both electrohydraulic and electromagnetic devices. Another problem in this regard is what was presented as insufficient experience. That factor might be much more important than the capacity of the lithotripter. In too many departments too little efforts are devoted to optimize SWL. Placing SWL in the hands of ever so efficient technicians or young colleagues with a more or less stereotypic treatment strategy does not serve the purpose of top level results.

Why the cost is mentioned as a factor that has decreased utilization of SWL is not understood. With a reasonable number of patients and well-organized lithotripsy service and strategy carried out with attention to all factors that are necessary to consider for successful SWL, this stone removing method is less expensive and associated with fewer complications than any of the other stone removing procedures.

The bottom-line of the aspects I have discussed above is that with an increased ambition to be successful with SWL and with attempts to control the unlimited enthusiasm for endoscopic surgery, there would definitely be an opening for re-establishment of SWL as the basic method for stone removal. It is necessary to emphasize, however, that success with SWL does not come automatically. But the same is of course true also for the competing methods for stone removal.

This report is based on results from replies to a questionnaire delivered to more than 750 urologists in Turkey. Although the response rate was not higher than approximately 30 percent, the attitudes to different stone removing procedures seem to be representative for the global trends. But the most interesting part of the study can be found in the different explanations of why SWL was rated low.
More than 90% of the urologists replied that other treatment modalities had taken the place as the leading technology. This situation is indeed well recognized and it has for some time been obvious that the development of endoscopic instruments and improved methods for stone disintegration better have attracted the surgical minds of large groups of urologists.
The second reason for the changed methodology, emphasized by more than 70% of the urologists, is the low single session success rate. In this regard it is important to know that there is a considerable variation. Although repeated sessions often are the price that has to be paid for the non-invasive technique there is a wide range of re-treatments reflecting both how SWL treatment is carried out and the performance of the lithotripter. There is no doubt that with increased focus on how to carry out SWL, much better results should be expected than those sometimes reported in the literature.
That the patients’ preference was given as a reason in more than 25% of the responses needs to be further analyzed in detail. It is highly likely that in the majority of cases patients’ preference directly reflects the methodological choice favored by the treating urologists. How the patient decides is most certainly strongly dependent on how the method is presented to the patient.
Limited indications for SWL were considered as one reason for not choosing SWL, but in fact the range of indications is much more extensive than generally considered. One amazing observation was that so few urologists used SWL for treatment of stones in the distal ureter. In the reviewer’s experience this is an excellent indication for SWL with very high stone free rates despite low need of repeated treatment.
According to Figure 1 in the article, approximately 8% of the urologists had obvious concerns about the function of the lithotripter that they had been using. One problem is that shockwave lithotripters sometimes are considered together with piezoelectric lithotripters. This is not fair because disintegration with piezoelectric lithotripsy is usually inferior to that accomplished with both electrohydraulic and electromagnetic devices. Another problem in this regard is what was presented as insufficient experience. That factor might be much more important than the capacity of the lithotripter. In too many departments too little efforts are devoted to optimize SWL. Placing SWL in the hands of ever so efficient technicians or young colleagues with a more or less stereotypic treatment strategy does not serve the purpose of top level results.
Why the cost is mentioned as a factor that has decreased utilization of SWL is not understood. With a reasonable number of patients and well-organized lithotripsy service and strategy carried out with attention to all factors that are necessary to consider for successful SWL, this stone removing method is less expensive and associated with fewer complications than any of the other stone removing procedures.
The bottom-line of the aspects I have discussed above is that with an increased ambition to be successful with SWL and with attempts to control the unlimited enthusiasm for endoscopic surgery, there would definitely be an opening for re-establishment of SWL as the basic method for stone removal. It is necessary to emphasize, however, that success with SWL does not come automatically. But the same is of course true also for the competing methods for stone removal.